APCHA Requalification Affidavit - 2019

By completing this form, you are declaring the below statements are true and accurate. You further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury.

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1.Full Name

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2.Unit Address

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3.Contact and Mailing Address Owner

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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4.Do you have roommates (besides a co-owner and/or children)?

Yes

No

If yes, please provide their names:

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5.Do you reside full-time in the deed-restricted home for 9 months or more per year?

Yes

No

If no, please explain:

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6.Are you employed 1,500 hours or more per year in Pitkin County (for a business that serves Pitkin County residents)?

Yes

No

Retired

Semi-Retired

If no, please explain

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7.Is this property the only residence you own in the Ownership Exclusion Zone (the land area in which is located any developed residential property that has an address within the Roaring Fork Drainage situated in Eagle, Pitkin, Garfield, or Gunnison Counties, or within the Colorado River Drainage from and including the unincorporated No Name area to and including Rifle, and including but not limited to, the incorporated areas of Aspen, Basalt, Carbondale, El Jebel, Glenwood Springs, Marble, Meredith, New Castle, No Name, Redstone, Rifle, Snowmass, Snowmass Village, and Woody Creek)?

Yes

No

If no, please explain:

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8.Are you the sole owner of the property? (i.e. the only name on the title)

Yes

No

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9.If no, please provide Contact Information for the Second Owner

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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10.Does the second owner reside full-time in the deed-restricted home for 9 months or more per year?

Yes

No

If no, please explain:

Question Title

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11.Is the second owner employed 1,500 hours or more per year in Pitkin County (for a business that serves Pitkin County residents)

Yes

No

Retired

If no, please explain

Question Title

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12.Is this property the only residence the second owner owns in the Ownership Exclusion Zone (the land area in which is located any developed residential property that has an address within the Roaring Fork Drainage situated in Eagle, Pitkin, Garfield, or Gunnison Counties, or within the Colorado River Drainage from and including the unincorporated No Name area to and including Rifle, and including but not limited to, the incorporated areas of Aspen, Basalt, Carbondale, El Jebel, Glenwood Springs, Marble, Meredith, New Castle, No Name, Redstone, Rifle, Snowmass, Snowmass Village, and Woody Creek)?